Anticoagulation in advanced Chronic Kidney Disease

Exploring and guiding current prescribing practice in the UK.

Project Partners

  • Manchester University NHS Foundation Trust
  • The University of Manchester
  • Manchester Kidney Patient Research Advisory Group
  • British Society of Haematology
  • NIHR Devices for Dignity HRC

Health and Care Requirement

Blood thinning medications, known as anticoagulants, are high risk medications because under-dosed patients are at risk of blood clots and over-dosed patients are at risk of bleeding, often with fatal consequences. Patients with chronic kidney disease (CKD) are at higher risk of experiencing both clotting and bleeding episodes than those with normal kidney function. There exists a thin line between the risks (bleeding and clots) and benefits (improved survival) of anticoagulation in kidney patients. This makes anticoagulant use in this group of patients more complex.

There is strong evidence that patients with CKD have an increased risk of atrial fibrillation, which can lead to stroke. However, these patients also have an increased risk of bleeding without any anticoagulation compared to those with normal kidney function. Unfortunately, there are still large gaps in what is known about the use of blood thinning drugs in this population. This means that treatment decision is highly variable as it is challenging for health professionals when making anticoagulation decisions to decide what might be best for the patient. Discussions with patients are difficult as there is not enough information available to help them to make an informed decision about their treatment options. There is no information regarding CKD patient perspectives on the risks and benefits of anticoagulant therapy. This study aims to explore some of these ideas and perspectives.

The Project Concept

Patients’ knowledge of their medication and medical condition can affect treatment outcomes, and this becomes more critical in patients prescribed oral anticoagulants due to the narrow window of safety of this class of medication, and the potentially devastating sequelae of both under and over treatment.

This study aims to identify differences in prescribing and reasons for these differences. The study will undertake a nationwide survey of current practice and follow this up with in-depth interviews with clinical staff. Patient’s views will be sought to help understand their concerns and ideas. This will help form the basis of a guideline that will be agreed upon between patients and clinicians. This document should support both clinicians and patients when making difficult decisions around anticoagulant treatment.

D4D are providing:

  • D4D Kidney Care Co-Theme Lead Professor Sandip Mitra is providing project supervision
  • Input into survey design
  • Input into widening dissemination and potential impact

Potential impact:

This work will produce a best practice guideline for anticoagulant prescribing for use across the UK, supporting staff involved in the care of patients with advanced CKD, providing a standardised approach to anticoagulation and ensuring patients receive a high quality of care regardless of location. A guide will provide clinicians with greater confidence when making difficult decisions in an area not well populated with good quality evidence. Included in this guide will be a section for clinicians on what patients want to know to address their main priorities.  A patient guide will be co-produced with information and questions patients feel important to raise with their clinician. This should reduce the disconnect between the patient and prescriber when having discussions around anticoagulation and promote balance in the consultation. It should also encourage better patient engagement in treatment discussions which has been shown to improve adherence to therapy and lead to improvement in patient outcomes.

Funding

Project Lead Kathrine Parker is in receipt of £267,280 NIHR Doctoral Fellowship funding.